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Introduction to Assessment Nur 869

Introduction to Assessment Nur 869. Lab 1. Assessment. Systematic & continuous collection, validation, and communication of client data Nursing process Initial and ongoing Medical vs Nursing Essential components. Purposes of Assessment. Obtain Baseline Date regarding functional abilities

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Introduction to Assessment Nur 869

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  1. Introduction to AssessmentNur 869 Lab 1

  2. Assessment • Systematic & continuous collection, validation, and communication of client data • Nursing process • Initial and ongoing • Medical vs Nursing • Essential components

  3. Purposes of Assessment • Obtain Baseline Date regarding functional abilities • Supplement, confirm, or refute date obtained in nursing history • Obtain data that helps establish nursing diagnoses and plan care • Evaluate physiologic outcomes of health care and thus client progress • Screen for presence of risk factors

  4. Types of Assessment • Initial • Focused • Emergency • Ongoing

  5. Objective Data “signs” info perceived by the senses Ex: T 101, moist skin Subjective Data “symptoms” info perceived only by affected person Ex: feeling nervous, tired Types of Data

  6. Characteristics of Data • Complete • Factual & Accurate • Relevant

  7. Problems r/t Data Collection • Organization • Omission • Irrelevant or Duplicate Data • Misinterpretation • Too little data • Documentation

  8. Why is a health history taken? • Patterns of wellness/illness • Physical & Behavioral risk factors • Deviations from norm • Nurse as a resource

  9. Health Perception/ Management Nutritional-Metabolic Elimination Activity-Exercise Sexuality-Reproduction Sleep-Rest Sensory-Perceptual Cognitive Role-Relationship Coping-Stress Tolerance Value-Belief Functional Health Patterns

  10. Chief Complaint Present Problem Usual health status Chronological story Impact on functioning Medications Past Medical History Family History Personal & Social History Review of Systems or Functional Patterns Nursing Health History

  11. Biographical Data Chief Complaint History of Present Illness Current Medications Current Treatments Past Illnesses or Past Hospitalizations Allergies Client Profile – UK Clinical Setting

  12. Age/Sex/Race Mental Status Behavior Mood Appearance Body Type Posture Body Mechanics Speech Use of language Thought Process Reliability as historian Height/Weight Vital Signs General Survey – Clinical Setting

  13. Explanation- Affect/Mood • Affect – observable behaviors which indicate the feelings or emotional status of the client. • Mood – term which refers to the client’s emotional state as described by the client.

  14. Affect Broad Restricted Blunted Flat Labile Mood Appropriate Inappropriate Depressed Anxiety Agitated Elated Manic Euphoric Euthymic (normal) irritable Documentation Terms

  15. General Principles - History • Explain purpose • Communication techniques • Utilization of data sources • Document • Avoid interruptions or tiring the client • Consider client’s developmental level

  16. Pediatric Parent/child interactions Integrate child Respect adolescent, give choices Geriatric Do not stereotype Assess and accommodate: sensory & physical functioning Developmental Principles

  17. Psychosocial Considerations - History • Avoid stereotypes • Healthcare beliefs • Language differences • Eye contact • Non-judgmental • Stressors/Coping Mechanisms

  18. Cultural Awareness Considerations • Time Orientation • Activity Orientation • Human Nature Orientation • Human-Nature Orientation • Relational Orientation • Seidel, 2003, pp. 43.

  19. Name Race Age Gender Marital status Birthplace, date Address Source of medical care Insurance coverage History - Biographical Data

  20. Past Health History • Previous hosp. & surgeries • Allergies • Illnesses & Accidents • Immunizations • Medications • Habits/Lifestyle • ADLs

  21. Client’s Family History • Blood relatives • Significant others • Health history • Family as resource • Stressors in family

  22. Present Illness/Health Concerns • Onset • Duration • Location, quality, and intensity • Precipitating factors • Relief factors • Client’s expectations • Subjective and Objective data

  23. PQRST – Characterize Symptoms • Precipitating factors • Quality • Radiation • Severity • Temporal Factors

  24. OLD CARTS – • Onset • Location • Duration • Character • Aggravating factors • Relieving factors • Temporal factors • Severity

  25. Reasons for Seeking Healthcare • Chief complaint • Why? • Quotes • Specify • Clarify

  26. Resources • Home and outside environment • Community resources • Financial • Family & significant others • Consider Basic Human Needs

  27. Medical Diagnostic Data • Medical vs Nursing Diagnosis • Nursing Implications r/t Medical Diagnosis

  28. Contributions of Lab Data • Verifies data • Provides baseline information • Evaluates outcomes • Identifies problems missed in history and assessment

  29. Test: Complete Blood Count(CBC) • Analysis of peripheral venous blood specimen • Main components: • RBC = red blood cell count (erythrocytes) • WBC = white blood cell count (leukocytes) • Hgb = hemoglobin • Hct = hematocrit

  30. Test: Urinalysis (UA) • Analysis of a urine specimen • Screens for: • urinary infection • renal disease • diabetes mellitus

  31. Urinalysis • Main components • pH- 4.6 - 8.0 • Protein- up to 10mg/100ml • Specific gravity- 1.003 - 1.030 • Glucose- negative • Ketones- negative • Blood- up to 2 RBCs

  32. Test: Electrolytes (lytes, e-) • Inorganic substances in the body that conduct electrical current • Usage: • Assess fluid balance

  33. Electrolytes • Main Components: • Na+ sodium • K+ potassium • Cl- chloride • Ca calcium • P phosphate • Mg magnesium

  34. Test: Chest X-Ray (CXR, PA Chest, PA & LAT Chest) • Radiographic exam of the thorax • Visualizes respiratory & cardiac function • Identifies & follows progression/ remission of dx process

  35. Test: Arterial Blood Gas (ABG) • Assesses the adequacy of ventilation and oxygenation via arterial blood • Use: measures respiratory and metabolic (renal) disturbances

  36. Arterial Blood Gases • Main Components: • pH • PaCO2 • PaO2 • HCO3 • SaO2

  37. General Nursing Implications • Assess client’s readiness to learn • Explain procedure to client • Assist client in dealing with the test • Provide privacy • Prepare client for test • Universal precautions • Send specimens promptly

  38. Specific Nursing Implications • Electrolytes: • Note diet, food and fluid intake • Note s/s that could affect fluid balance (N/V/D) • Chest X-Ray: • Transport • Remove metal objects • Stand clear

  39. Specific Nursing Implications • Arterial Blood Gases • Anticoagulants? • Time drawn • Check site for bleeding • Pressure • Sample on ICE • STAT to lab

  40. Physical Assessment:Pediatric Principles • Assess: • coping ability • previous knowledge • readiness • Encourage questions • Explain at developmental level

  41. Physical Assessment:Pediatric Principles • Use concrete terms • Small amounts of info at a time • Simple & clear explanations • Only offer choices that are available • Honest praise/rewards

  42. Physical Assessment Methods • Inspection • Palpation • Auscultation • Percussion

  43. Equipment • Stethoscope • Pen light • Blood Pressure Cuff • Thermometer • Watch with second hand

  44. Inspection • Assessment process during which the nurse observes the client

  45. Inspection • Initial contact and ongoing • Use olfaction, touch • General appearance, body language • Systematic unhurried approach • Expose part, respect privacy • Examine: color, size, shape, position, symmetry (compare like areas) • Know “normals” • Observe “normals/abnormals”

  46. Palpation • The use of the hands and the sense of touch to gather data

  47. Palpation • Detects texture, shape, temp, movement, pain, moisture • Short fingernails, warm hands • Gentle approach • Light palpation first, if pain - STOP! • Palpate tender areas last • Three types: • Light palpation (1/2 inch) • Deep palpation (1 inch) • Bimanual deep palpation (2 hands)

  48. Auscultation • The act of listening to sounds within the body to evaluate the condition of body organs • (stethoscope)

  49. Auscultation • Stethoscope: • bell for low pitch sounds (cardiac sounds) • Diaphragm for high pitch sounds (bowel, breath, normal cardiac) • 4 characteristics of sounds • Frequency/pitch: # vibrations per second • Loudness: soft, medium, loud • Quality: types; gurgling, blowing • Duration: short, medium, long (specify)

  50. Auscultation • Quiet environment • Know landmarks • Know “normals” • PRACTICE! PRACTICE! PRACTICE! • Requires concentration, practice, and application of knowledge

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